Allograft ACL Repair Questioned in Young Active Patients

Action Points

Explain to interested patients that in reconstructing the anterior cruciate ligament, physicians can use either the patient's own tissue or tissue from cadavers.

Note that this study suggests that using cadaver allografts may not be the best choice for patients under 40 who take part in activities that stress the knee.

ORLANDO, July 10 -- Using tissue from cadavers to reconstruct anterior cruciate ligaments in young active patients is associated with a failure rate of nearly 25%, a researcher said here.

In a case series study, patients with a high activity level both before and after a transplant were significantly more likely to have their new ligaments fail than were patients who participated in less strenuous sports, according to Kurre Luber, M.D., of the Mississippi Sports Medicine and Orthopaedic Center in Jackson, Miss.

That finding suggests that fresh-frozen allografts may not be the best choice for high-performance athletes who need anterior cruciate ligament (ACL) repair, Dr. Luber told attendees at the annual meeting of the American Orthopaedic Society for Sports Medicine.

"This study found a very high failure rate in patients 40 years and younger with high activity levels in ACL-dependent sports like tennis, basketball, soccer and downhill skiing," Dr. Luber said in a statement.

He added that other factors, such as surgical technique, may also play a role in the high failure rate. "However, this study definitely raises questions about the validity of using cadaver tissue in this patient subgroup," Dr. Luber said.

An earlier study from the same group found a failure rate of 2.4% among patients older than 40 who got a ligament from a cadaver. Compared to that, Dr. Luber and colleagues said, the 23.4% rate in this analysis is "exceedingly high."

The researchers retrospectively analyzed data on 64 patients who had a primary fresh frozen bone-patella tendon-bone allograft ACL reconstruction at their center between 1993 and 2005.

Failure of the procedure was defined as the need for a second reconstruction because of injury or graft failure or poor scores on a combination of orthopedic outcome measures.

Activity level was measured on the Tegner scale, whose highest score, 10, is reserved for those who play national and international soccer. The lowest scores --- one and zero -- cover people who are in sedentary work and whose physical activity stops at walking on level ground, as well as those on sick leave or disability pension because of knee pain.

In the study group, 15 patients met the criteria for failure after a mean follow-up of 57 months. Analysis found:

The failure group had a mean pre-injury Tegner activity score of 6.47, with a range of six to seven, compared with 5.59, with a range of three to seven, for those whose grafts did not fail. The difference was statistically significant at P=0.04.

Those who failed also resumed activity at a higher Tegner level of 5.93, with a range of three to seven, compared with 4.86, with a range of two to seven for the non-failure group. The difference was significant at P=0.018.

Among the 15 whose grafts failed, three had revision reconstruction, one had a partial debridement of the ACL stump, and one had a failed thermoplasty of the ACL, Dr. Luber said. The remaining patients modified their activity level.

The use of ligaments from cadavers is growing in popularity because it avoids the need for a second surgical site to harvest autologous tissue for the graft. That, in turn, lessens post-operative pain and speeds up the return to work and normal activity.

But, "for a young patient who is very active, it may not be the right choice," said co-author Gene Barrett, M.D., also of the Mississippi Sports Medicine and Orthopaedic Center.

Dr. Luber and colleagues said young, active patients should be counseled about the high risk of failure during the graft selection process.

The researchers did not report any external support for the study or any conflicts.

Reviewed by Zalman S. Agus, MD Emeritus Professor University of Pennsylvania School of Medicine

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